For your convenience, below are important forms and documents to help you easily manage your health coverage.
Privacy practices and advance directives
- Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information.
- HIPAA Privacy Practices and Forms contains privacy information and documentation related to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
- Information on Advance Directives. For more information or a copy of the Advance Directive form, contact us.
Claim reimbursement forms
To request a reimbursement for a cataract glasses purchase, please complete the Cataract Glasses Reimbursement Form and submit to the Independence Blue Cross Claims Department at the address listed on the form.
To request a reimbursement as a Personal Choice 65 PPO Member for a non-network claim, please complete the Non-network claim form and submit to the Independence Blue Cross Claims Department at the address listed on the form.
As a member of Keystone 65 HMO or Personal Choice 65SM PPO, you are covered for an influenza vaccine each year. If you received your vaccine at a non-participating provider and paid out of pocket, you can use the following forms to apply for reimbursement.
- Keystone 65 HMO Influenza Vaccine Reimbursement Form
- Personal Choice 65® PPO Influenza Vaccine Reimbursement Form
Summary of Benefits
2021 Summary of Benefits
- Keystone 65 Basic HMO, Keystone 65 Focus HMO, Keystone 65 Select HMO Summary of Benefits
- Keystone 65 Preferred HMO Summary of Benefits
- Personal Choice 65 PPO Summary of Benefits
Call us at 1-877-393-6733 (711 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week. However, please note that on weekends and holidays from March 31 through September 30, your call may be sent to voicemail.
Extra help is available for those who need it most. Find out whether you qualify for low-income subsidy.
Evidence of Coverage and Outline of Coverage
The Evidence of Coverage (EOC) is a comprehensive resource guide to your health care coverage. It explains your benefits, premiums, and cost-sharing; conditions and limitations of coverage; and plan rules.
After you've joined the plan, you will receive the Evidence of Coverage in the mail. This is a legal document that should be kept in a safe place.
2021 Evidences of Coverage
- Keystone 65 Medical-Only HMO Evidence of Coverage
- Keystone 65 Rx HMO Evidence of Coverage
- Personal Choice 65SM Medical-Only PPO Evidence of Coverage
- Personal Choice 65SM Rx PPO Evidence of Coverage
MedigapFreedom, MedigapSecurity, and Security 65 Outlines of Coverage
- MedigapFreedom Individual Outline of Coverage
- MedigapFreedom Individual Private Exchange Outline of Coverage
- MedigapFreedom Group Outline of Coverage
- MedigapSecurity Group Outline of Coverage
Use a Change Form to move from one plan to another plan. For example, you can use a Change Form to move from Keystone 65 Preferred HMO to Keystone 65 Select HMO or Personal Choice 65 Medical-only PPO to Personal Choice 65 Rx PPO. This change can only occur during a valid Election Period.
Please keep in mind that you cannot use a change form to switch between Personal Choice 65SM PPO, a Blue Cross Medicare Advantage PPO Plan from QCC Insurance Company and Keystone 65 HMO, a Blue Cross Medicare Advantage HMO Plan from Keystone Health Plan East.
2021 Change Forms
2021 Keystone 65 HMO
Keystone 65 HMO
PO Box 7799
Philadelphia PA 19101-7799
2021 Personal Choice 65
Personal Choice 65 PPO
PO Box 7799
Philadelphia PA 19101-7799
Online Plan Changes
To complete a Keystone 65 HMO or Personal Choice PPO plan change online:
- Visit the iQuote online tool
- Select Enroll Now
- Enter birthdate, zip code, county, and coverage start date
- Select Add to cart on the desired plan
- Select the plan in your cart, and select apply now
- Select yes when asked if you are a current IBX plan member
- Enter Member ID, first and last name and select continue
- Complete the enrollment form
Annual Notice of Changes
2021 Annual Notice of Changes
- Keystone 65 Basic Rx HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Keystone 65 Basic Rx HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Keystone 65 Focus Rx HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Keystone 65 Focus Rx HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Keystone 65 Preferred Medical-Only HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Keystone 65 Preferred Medical-Only HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Keystone 65 Preferred Rx HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Keystone 65 Preferred Rx HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Keystone 65 Select Medical-Only HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Keystone 65 Select Medical-Only HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Keystone 65 Select Rx HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Keystone 65 Select Rx HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Personal Choice 65 Medical-Only PPO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Personal Choice 65 Prime Rx PPO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Personal Choice 65 Prime Rx PPO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Personal Choice 65 Rx PPO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Personal Choice 65 Rx PPO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Keystone 65 HMO Electronic Funds Transfer (EFT) Form
- Personal Choice 65 PPO Electronic Funds Transfer (EFT) Form
- Select Option PDP Electronic Funds Transfer (EFT) Form
Below are the disenrollment forms available to you. Please read these important instructions regarding requesting disenrollment from the plan.
Medicare Advantage disenrollments
When can I make changes to my Medicare coverage?
You can make plan changes, such as requesting disenrollment, only at certain times during the year. From October 15 through December 7 each year, anyone can make any type of change including adding or dropping Medicare prescription drug coverage. From January 1 through March 31, anyone enrolled in a Medicare Advantage plan (except for MSA plans) has an opportunity to enroll in a different Medicare Advantage plan or disenroll from their Medicare Advantage plan and return to Original Medicare. You may make only one election during this period. Anyone who disenrolls from a Medicare Advantage plan during this time can join a stand-alone Medicare Prescription Drug Plan during the same period. If you join a Medicare Prescription drug plan, you will be automatically disenrolled from our plan and returned to Original Medicare. Generally, you may not make changes at other times unless you meet certain special exceptions, such as if you move out of the plan's service area, want to join a plan in your area with a 5-star rating, or qualify for extra help with your prescription drug costs. If you qualify for extra help with your prescription drug costs you may enroll in, or disenroll from, a plan at any time. If you lose this extra help during the year, your opportunity to make a change continues for two months after you are notified that you no longer qualify for extra help.
What is extra help?
People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify won't have a coverage gap or a late enrollment penalty. Many people qualify for these savings and don't even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.
When should I fill out the disenrollment request form?
You should fill out the appropriate disenrollment form during a valid election period, if you want to change to Original Medicare only and do not want Medicare prescription drug coverage.
You shouldn't fill out the appropriate disenrollment form if you are planning to enroll, or have enrolled, in another Medicare Advantage plan or other Medicare health plan. Enrolling in another Medicare plan will automatically disenroll you from our plan.
You shouldn't fill out the appropriate disenrollment form if you are enrolling in a Medicare prescription drug plan. Enrolling in a Medicare prescription drug plan will automatically disenroll you from the plan to Original Medicare.
Until your disenrollment date, you must keep using the plan's doctors. To avoid any unexpected expenses, you may want to contact us to make sure you've been disenrolled before you seek medical services outside of the plan's network.
How do I submit the disenrollment request?
If you want Original Medicare, as described above, you may fill out the appropriate disenrollment form during a valid election period, sign it, and send it back to us at:
Independence Blue Cross
P.O. Box 7330
Philadelphia, PA 19101-8957
You can also fax the form with a readable signature and date to us at 1-215-241-2275.
You can call 1-800-MEDICARE (1-800-633-4227) for information about Medicare plans available in your area. TTY users should call 1-877-486-2048, 24 hours a day/7days a week.
What are my Medigap rights?
If you will be changing to Original Medicare, you might have a special temporary right to buy a Medigap policy, also known as Medicare supplemental insurance, even if you have health problems. For example, if you are age 65 or older and you enrolled in Medicare Part B within the past 6 months or if you move out of the service area, you may have this special right.
Federal law requires the protections described above. Your State may have laws that provide more Medigap protections. If you have questions about Medigap or Medigap rights in your State, you should contact your State Health Insurance Program APPRISE at 1-800-783-7067. You can also call 1-800-MEDICARE (1-800-633-4227) anytime, 24 hours a day, 7 days a week for more information about trial periods. TTY users should call 1-877-486-2048.
If you need any help, please contact the Member Help Team.
Medicare Advantage disenrollment forms
Typically, you may disenroll from a Medicare Advantage plan only during the Annual Enrollment Period from October 15 through December 7 of each year or during the Medicare Advantage Open Enrollment Period from January 1 through March 31 of each year. There are exceptions that may allow you to disenroll from a Medicare Advantage plan outside of this period. If you are disenrolling from the plan outside of the Annual Enrollment Period or the Medicare Advantage Open Enrollment Period, please also submit the following Disenrollment Election Form with your Disenrollment Form.
- Keystone 65 Basic Rx HMO Disenrollment Form
- Keystone 65 Focus Rx HMO-POS Disenrollment Form
- Keystone 65 Select Medical-only HMO Disenrollment Form
- Keystone 65 Select Rx HMO Disenrollment Form
- Keystone 65 Preferred Medical-only HMO Disenrollment Form
- Keystone 65 Preferred Rx HMO Disenrollment Form
- Personal Choice 65SM Medical-only PPO Disenrollment Form
- Personal Choice 65SM Rx PPO Disenrollment Form
- Personal Choice 65SM Prime Rx PPO Disenrollment Form
2021 Medicare Advantage grievances information
- For more information on Keystone 65 Medical-only HMO grievances, please reference Chapter 7, Section 9.3 on page 147 in your EOC or view Keystone 65 Medical-only HMO Grievances
- For more information on Keystone 65 Rx HMO grievances, please reference Chapter 9, Section 10.3 on page 222 in your EOC or view Keystone 65 Rx HMO Grievances
- For more information on Personal Choice 65SM Medical-only PPO grievances, please reference Chapter 7, Section 9.3 on page 155 in your EOC or view Personal Choice 65SM Medical-Only PPO Grievances
- For more information on Personal Choice 65SM Rx PPO grievances, please reference Chapter 9, Section 10.3 on page 225 in your EOC or view Personal Choice 65SM Rx HMO PPO Grievances
Medicare Advantage Open Enrollment Period (OEP)
The OEP begins on the first day of the calendar year and ends on March 31 of that same year. During the OEP, an individual enrolled in a Medicare Advantage (MA) plan may prospectively disenroll from that plan and enroll in a different Medicare Advantage plan (with or without Part D) or return to Original Medicare. The effective date of the disenrollment from the MA plan is the first day of the month following the date the disenrollment request is received thus, disenrollment requests received by MA organization in January are effective February 1; those received in February are effective March 1; and those received in March are effective April 1. The OEP does not provide an opportunity for those enrolled in Original Medicare only to join a Medicare Advantage plan. It also does not allow for Part D changes for individuals enrolled in Original Medicare, including those enrolled in stand-alone Part D plans.
Medicare Supplement (Medigap) disenrollments
Please complete the following form to cancel Security 65 or MedigapSecurity plan coverage. Once you have completed and signed the form, please mail or fax to:
Independence Blue Cross
P. O. Box 13713
Philadelphia, PA 19101-3713
Cancellation Request Forms (without Estate)
Cancellation Request Forms (with Estate)
Appointment of a representative
If you have someone appealing our decision for you other than your physician, your appeal must include an Appointment of Representative form. The person taking action on your behalf is called an appointed representative. You can name a relative, friend, advocate, lawyer, or anyone else to be your appointed representative. If you want someone to act for you, then you and that person must sign and date an Appointment of Representative form that authorizes the person to act as your appointed representative.
This statement must be sent to us at:
Medicare Appeals Unit
P.O. Box 13652
Philadelphia, PA 19101-3652
You can call the Member Help Team to learn how to name your appointed representative.
Standards of care
The Independence Blue Cross Quality Management program monitors and objectively evaluates standards and quality of care for our members.
The Quality Management program:
- Provides tools and information to assist network providers in developing and maintaining a high standard of care;
- Manages partnerships with network providers;
- Monitors and evaluates the care our members receive;
- Suggests improvements to medical policies;
- Oversees provider credentialing;
- Oversees various processes for hearing grievances and appeals;
- Collects member suggestions for quality initiatives;
- Monitors aspects of care based on the demographics of members served (i.e., age, sex, and health status);
- Investigates and tracks potential quality-of-care concerns through the recredentialing, grievance and appeal, and peer review processes.
We communicate member safety initiatives through newsletters and mailings to increase awareness and reduce medical and medication errors.
We take all member feedback seriously. We thoroughly investigate and aim to resolve all quality-of-care and quality-of-service issues. Any member may file a concern or complaint in writing or by calling Customer Service at the number listed on back of his or her ID card.
Continuity and coordination of care
We assess coordination and continuity of care against three criteria:
- How well care is coordinated among medical providers who are treating the same patient;
- How well medical and behavioral care are coordinated;
- When a provider leaves a network, how well we ensure that his or her patients under active treatment have continuous access to care.
When a member is receiving an active course of treatment and his or her practitioner leaves the health plan, the member may be eligible for continued access to the practice for a time period mandated by specific state regulations. The health plan will notify the member in writing that his or her provider has left the network and assist the member in arranging the continuation of care and selection of a new practitioner.
Information about our Quality Improvement program is available to members and providers. Upon request, we'll provide a description of our program and a report on progress. For member requests, call the Member Services number listed on the back of the ID card.
For additional details, view our Quality Management Program flyer.
Benefits during disasters
In the event of a Presidential emergency declaration, a Presidential (major) disaster declaration, a declaration of emergency or disaster by a Governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, but absent, or prior to the issuance of, a section 1135 waiver by the Secretary, Independence Blue Cross will:
- Allow beneficiaries to seek care at specified non-contracted facilities (note that Part A and Part B benefits must be furnished at Medicare certified facilities);
- Waive in full, requirements for referrals where applicable;
- Pay out of network claims, or claims where prior authorization/referrals were not obtained at the in-network benefit level;
- Allow members to seek care from non-network providers at the in-network benefit level;
- Waive the 30-day notification requirement to enrollees as long as all the changes (such as reduction of cost-sharing and waiving authorization) benefit the enrollee and;
- Lift refill-too-soon edits for Part D prescription drugs;
Typically, the source that declared the disaster will clarify when the disaster or emergency is over. If, however, the disaster or emergency timeframe has not been closed 30 days from the initial declaration, and if CMS has not indicated an end date to the disaster or emergency, Independence Blue Cross will resume normal operations 30 days from the initial declaration.
Non-discrimination Notice and Multi-Language Insert
The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan's performance to other plans.
Website last updated: 12/4/2020